MEDI-CAL OVERVIEW

What is Medi-Cal?

Medi-Cal is California’s Medicaid program and has served state residents since 1966. Medicaid is a medical assistance program established by Title XIX of the Social Security Act. The Medicaid program is a no-cost or low-cost public health insurance program that provides needed health care services for low-income and disabled individuals.

The Medicaid program is an entitlement program that is jointly financed by the state and federal governments and administered by the states. The Medicaid program is intended to provide a consistent health care program for the poor, while allowing some variation on coverage and eligibility within the States.

Who is covered under the Medi-Cal Program?

Californians are automatically eligible for Medi-Cal with no share of cost if they receive benefits from one of the following programs:

SSI/SSP,

CalWorks (TANF),

Refugee Assistance,

Foster Care, or

Adoption Assistance.

Persons who meet particular income and resource requirements are potentially eligible for Medi-Cal benefits if they are:

65 or older

Blind

Disabled

Under 21

Pregnant

In a skilled nursing or intermediate care home

On refugee status for a limited time, depending how long you have been in the United States

The Medi-Cal offers a broad range of services.Some services are federally mandated, while the state has elected to offer optional services available under the Medicaid program.Medi-Cal services include, but are not limited to:

Inpatient and Outpatient Hospital Care

Physician and Clinic services

Laboratory and X-ray Services

Skilled Nursing Facility services

Home Health Services

Home and Community-Based Services

Renal Dialysis Services

Mental Health Services

Dental Services

Personal Care Services

The availability of services may be limited to certain eligible groups.All services rendered must meet certain requirements, including medical necessity and may be require prior authorization.

How are Medi-Cal Services Delivered?

The Medi-Cal program operates under two primary care delivery models:Fee-For-Service (FFS) Medi-Cal and Medi-Cal Managed Care. In the FFS Medi-Cal model, health care providers are reimbursed through a Medi-Cal Fiscal Intermediary.In the Medi-Cal Managed Care model, the California Department of Health Care Services contracts with health insurance organizations to provide services to groups of Medi-Cal eligibles in specific counties.Benefits paid under the Medi-Cal Managed Care plan vary by contract and any non-covered managed care services are paid through the FFS Medi-Cal delivery model.Specialty Medi-Cal programs such as Mental Health, Developmental Services and Personal Care Services are administered through other state departments.